A money-back guarantee for hospital care

The issue: Improving satisfaction among patients discontent with their hospital stay.

Background

In August 2015, a patient who had undergone spinal surgery at Geisinger Health System
complained that he wasn't given an adequate explanation of his $1,000 insurance copayment
for a recent surgery, said Jonathan Slotkin, MD, director of spinal surgery for Geisinger's
Neurosciences Institute.

Initially, the patient simply wanted to convey his situation to Geisinger president
and CEO David Feinberg, MD, MBA, who then instructed that he be refunded the $1,000.
But by the time Dr. Slotkin met with his patient, the man said he didn't want any
money back; he didn't care as much about the money as improving the situation for
future patients. “I said, ‘We feel we should've done better. You should
take the money back,’” Dr. Slotkin recounted. “By the time he
left, he was going to take back $500 in a refund.”

This situation led Drs. Feinberg and Slotkin to think about doing this on a larger
scale. “We were talking about that patient, and then the idea came out of that
conversation about building an app to facilitate refunds and making it a formal program,”
said Dr. Slotkin, who is also medical director of Geisinger in Motion, which develops
mobile device technology as part of the health system's Division of Applied Research
and Clinical Informatics.

How it works

The result, launched as a pilot in November 2015, is an app that allowed for the refunding
of copayments on a sliding scale to patients undergoing bariatric or spinal surgery.
It was initially offered to about a dozen patients, whom were chosen because they
have larger copays: about $2,000 for bariatric surgery and $1,000 for spinal surgery.
“We wanted the copayment to be large because we wanted the program to move
the needle,” Dr. Slotkin said. “If we were talking about refunding a
$5 copay for a visit, we didn't think that was going to wake up the institution and
its associates to the importance of the project.”

The goal of the program is not only to satisfy patients by refunding their costs when
they are displeased with their experience but also to identify flaws in the health
system's care processes. “The key piece is the feedback we get from patients.
We call anybody that uses this program to ask for a refund to ask where we went wrong.
Then, we engage the service areas or disciplines where that issue took place, and
we work to make it not happen again,” said Dr. Slotkin.

The bariatric surgery patient reported concerns about the environment of care, specifically
construction noise, Dr. Slotkin said. The patient also mentioned a painful IV she
felt wasn't addressed quickly enough, as well as some displeasure with the financial
structuring of the copayment itself.

The patient who requested a partial refund cited food items that did not come quickly
enough and the fact that Geisinger's finance office requested a partial down payment
before the surgery. “For that patient, that $150 is symbolic. They're sending
a message to the system that the overwhelming part of what they had done went well,
but then the following issues were not great,” Dr. Slotkin said.

Since the program's launch, Geisinger's patient experience team has received more
than 55 calls from patients inquiring about or asking for refunds. Because these patients
were not part of the pilot, those requests were handled on a case-by-case basis, Dr.
Slotkin said.

The refund program is focused on patients' subjective sense of their experience, and
Geisinger was willing to give a refund to anyone in the pilot who asked for one, he
said.

Program leaders aren't worried about whether patients will be dishonest. “What
we felt was that our patients put their trust in us, so we should put our trust in
our patients. We did not suspect there would be widespread misuse or dishonesty, and
we have not seen that there's been. We felt that the loyalty it would engender in
people would far outweigh any dishonesty,” Dr. Slotkin said.

Challenges

For clinicians, having a patient ask for a refund could cause them to feel that they've
done something wrong. “I personally ran into that being the guinea pig in the
pilot,” said Dr. Slotkin. When a patient complains through the refund program,
the physician is made aware, “but this is not a punitive program by any means,
and very rarely do patients complain about their doctor or the care provided [to]
them,” he said. Most times, dissatisfaction is related to incidentals such
as lunch being delivered late or billing issues.

Others on the hospital staff are still leery of the program, he added. “Some
providers, administrators, and staff members believe that this type of program is
a financial mistake or risky, and what folks need to learn is that if we succeed in
starting to extinguish these negative events and in growing more loyalty in our patients
and their family members, then the benefits of that are going to far outweigh the
small percentage on the margin of folks that are asking for refunds or partial refunds,”
Dr. Slotkin said.

There is no concern at this point about how much money the refund program will cost,
he said. Plans are to continue to evaluate the effects of the program as it moves
forward. “And quite honestly, this is a great opportunity for Geisinger to
see ProvenExperience [the refund program] as a ‘secret shopper’ program,
allowing us to witness how the entire continuum of care affects the patient experience,”
Dr. Slotkin said.

Technical challenges to the program include appropriately dispensing refunds and correcting
the related systemic issues. “You need to have a process for making the refund
occur quickly and reliably because the only thing worse than whatever went wrong in
the patient's service is then also not even getting the refund correct,” Dr.
Slotkin said. “And we need to make sure that we're building reliable backend
processes to prevent whatever it is the patient points out from happening again because,
if we keep duplicating the same mistakes, then this type of program is worthless.”

Next steps

Geisinger has rolled out the program to all areas of the health system and will soon
make the app available to all inpatients and outpatients, not just bariatric and spinal
surgery inpatients, Dr. Slotkin said. The goal is for the program to apply to every
patient's copayment, coinsurance, and deductible, and the app has been changed to
reflect this broader scope, he said. “Any of the patient's personal financial
responsibility will be on the line anytime a patient interacts with the system,”
Dr. Slotkin said. “And that's our skin in the game to commit all 30,000 Geisinger
employees to excellent patient experience.”

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.